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Amenorrhoea

I this article I discuss what Amenorrhoea is, the causes and symptoms of Amenorrhoea. I also discuss treatment options, both drugs and lifestyle choices.

What is it?

Amenorrhoea is the absence of menstruation — one or more missed menstrual periods. Primary amenorrhoea refers to no menstrual periods by age 16. Secondary amenorrhoea occurs when you were previously menstruating, but then stopped having periods. If you're sexually active and otherwise healthy, pregnancy is the most likely reason you've missed a period.

Besides pregnancy, there are many other possible explanations for amenorrhoea. A sign, not a disease, amenorrhoea seldom results from a serious condition. However, not knowing why menstruation has stopped can be stressful, and the time spent waiting for it to recur may feel like a lifetime. But once you and your doctor get to the root of the problem, treatment of the underlying condition often resolves amenorrhoea.

Symptoms

The main indication of amenorrhoea is that you don't have menstrual periods:

In primary amenorrhoea, you have no menstrual period by age 16.

In secondary amenorrhoea, you have no periods for three to six months or longer.

Depending on the cause of amenorrhoea, you might experience other signs or symptoms along with the absence of periods, such as milky nipple discharge, headache, vision changes, or excessive hair growth on your face and torso (hirsutism).

Causes

Secondary amenorrhoea

Secondary amenorrhoea is more common than primary amenorrhoea. Many possible causes of secondary amenorrhoea exist:

Pregnancy. In women of reproductive age, pregnancy is the most common cause of amenorrhoea. When a fertilized egg is implanted in the lining of your uterus, the lining remains to nourish the fetus and isn't shed as menstruation.

Contraceptives. Some women who take birth control pills may not have periods. When oral contraceptives are stopped, it may take three to six months to resume regular ovulation and menstruation. Contraceptives that are injected or implanted, such as Depo-Provera or Implanon, also may cause amenorrhoea as can progesterone-containing intrauterine devices, such as Mirena.

Breast-feeding. Mothers who breast-feed often experience amenorrhoea. Although ovulation may occur, menstruation may not. Pregnancy can result despite the lack of menstruation.

Stress. Mental stress can temporarily alter the functioning of your hypothalamus — an area of your brain that controls the hormones that regulate your menstrual cycle. Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases.

Hormonal imbalance. A common cause of amenorrhoea or irregular periods is polycystic ovary syndrome (PCOS). This condition causes relatively high and sustained levels of estrogen and androgen, a male hormone, rather than the fluctuating levels seen in the normal menstrual cycle. This results in a decrease in the pituitary hormones that lead to ovulation and menstruation. PCOS is associated with obesity; amenorrhoea or abnormal, often heavy, uterine bleeding; acne; and sometimes excess facial hair.

Low body weight. Excessively low body weight interrupts many hormonal functions in your body, potentially halting ovulation. Women who have an eating disorder, such as anorexia or bulimia, often stop having periods because of these abnormal hormonal changes.

Excessive exercise. Women who participate in sports that require rigorous training, such as ballet, long-distance running or gymnastics, may find their menstrual cycle interrupted. Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress and high energy expenditure.

Thyroid malfunction. An underactive thyroid gland (hypothyroidism) commonly causes menstrual irregularities, including amenorrhoea. Thyroid disorders can also cause an increase or decrease in the production of prolactin — a reproductive hormone generated by your pituitary gland. An altered prolactin level can affect your hypothalamus and disrupt your menstrual cycle.

Pituitary tumor. A noncancerous (benign) tumor in your pituitary gland (adenoma or prolactinoma) can cause an overproduction of prolactin. Excess prolactin can interfere with the regulation of menstruation. This type of tumor is treatable with medication, but on rare occasions, it requires surgery.

Uterine scarring. Asherman's syndrome, a condition in which scar tissue builds up in the lining of the uterus, can sometimes occur after uterine procedures, such as a dilation and curettage (D and C), cesarean section or treatment for uterine fibroids. Uterine scarring prevents the normal buildup and shedding of the uterine lining, which can result in very light menstrual bleeding or no periods at all.

Primary ovarian insufficiency. Menopause usually occurs between ages 45 and 55. In some women, the ovarian supply of eggs diminishes before age 40, a condition known as primary ovarian insufficiency. The lack of ovarian function associated with this condition decreases the amount of circulating estrogen in your body, which in turn thins your uterine lining (endometrium) and brings an end to your menstrual periods. Primary ovarian insufficiency, also referred to as premature menopause, may result from genetic factors or autoimmune disease, but often no cause can be found.

Primary amenorrhoea

Primary amenorrhoea affects less than 1 percent of adolescent girls. The most common causes of primary amenorrhoea include:

Chromosomal abnormalities. Certain chromosomal abnormalities can cause a premature depletion of the eggs and follicles involved in ovulation and menstruation.

Problems with the hypothalamus. Functional hypothalamic amenorrhea is a disorder of the hypothalamus — an area at the base of your brain that acts as a control center for your body and regulates your menstrual cycle. Excessive exercise, eating disorders, such as anorexia, and physical or psychological stress can all contribute to a disruption in the normal function of the hypothalamus. Less commonly, a tumor may prevent your hypothalamus from functioning normally.

Pituitary disease. The pituitary is another gland in the brain that's involved in regulating the menstrual cycle. A tumor or other invasive growth may disrupt the pituitary gland's ability to perform this function.

Lack of reproductive organs. Sometimes problems arise during fetal development that lead to a girl being born without some major part of her reproductive system, such as her uterus, cervix or vagina. Because her reproductive system didn't develop normally, she won't have menstrual cycles.

Structural abnormality of the vagina. An obstruction of the vagina may prevent visible menstrual bleeding. A membrane or wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix.

How is Amenorrhoea Diagnosed?

Although amenorrhoea rarely results from a life-threatening condition, it can encompass a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing, including:

Pregnancy test. This will probably be the first test your doctor does, to rule out or confirm a possible pregnancy.

Pelvic exam. Your doctor may also perform a pelvic exam to check for any problems with your reproductive organs.

Physical exam. Your doctor will perform a physical examination and ask about your medical history. In young women, this exam includes checking for signs and symptoms of changes that are normal to puberty.

Blood tests. Blood tests, such as a thyroid function test or evaluation of your prolactin level, can pinpoint inconsistencies in hormone levels that might be responsible for amenorrhoea. In women with increased hair growth, male hormone levels may be checked.

Progestin challenge test. For this test, you take a hormonal medication (progestogen) for seven to 10 days to trigger menstrual bleeding. Results from this test can tell your doctor whether your periods have stopped due to a lack of estrogen.

Laparoscopy or hysteroscopy. As a last resort, when other testing reveals no specific cause, your doctor may recommend a minimally invasive surgery to view your internal organs. Sometimes, any problems detected can be treated at the same time.

Treatments and drugs

Treatment depends on what's causing your amenorrhoea. Your doctor may suggest that you make changes to your lifestyle depending on your weight, physical activity or stress level. If you have PCOS or hypothalamic amenorrhoea, your doctor may prescribe oral contraceptives to treat the problem. Amenorrhoea caused by thyroid or pituitary disorders may be treated with medications.

Lifestyle remedies

The best way to avoid an interruption in your menstrual cycle is to maintain a healthy lifestyle:

Make changes in your diet and exercise activity to achieve a healthy weight.

Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.

Talk to your mother, sister or other close female relatives. Has anyone else in your family had a similar problem? Gathering this information can help your doctor determine what's causing your amenorrhoea.

Amenorrhoea may cause anxiety, but by working with your doctor, you can determine the cause and find ways to regulate your cycle.